OASIS-C What You Must Know National Association for Home Care Preconference October 10, 2009

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OASIS-C What You Must Know National Association for Home Care Preconference October 10, 2009 Deborah Deitz, RN, BSN, Abt Associates Angela Richard, RN, MSN, University of Colorado Elizabeth A. Madigan, RN, PhD, FAAN, Case Western Reserve University Clinician team for CMS 1

Objectives for today s preconference 1. Describe the rationale leading to development of the OASIS-C 2. Identify the different components of quality measurement and the rationale for inclusion of process items in OASIS- C 3. Describe the process of OASIS-C development and testing 4. Describe the findings of OASIS-C testing 2

Objectives (continued) 5. Identify major new components of the OASIS-C assessment instrument 6. Identify changes needed in agency operations with implementation of OASIS- C 7. Outline the major implications of the new assessment instrument for quality measurement and reporting 8. Describe steps for implementing quality improvement using OASIS-C 3

OASIS-C History & Background 4

What is OASIS? Outcome and Assessment Information Set Required for Medicare-certified HHAs since 1999 Originally designed for measurement of home health care patient outcomes; now used for multiple purposes 5

OASIS Quality Reports CMS has provided reports to HHAs to help guide quality/performance improvement efforts Risk-adjusted outcome reports (OBQI) comparisons over time comparisons to national benchmarking data Potentially avoidable event (adverse event outcomes) reports (OBQM) Agency/patient specific characteristics (agency case mix) reports Patient tally reports 6

OASIS Evolution Since 1999 Several minor OASIS revisions Comments from HH industry, providers, professional organizations and researchers IOM report set national policy goals Health care quality expert recommendations 7

OASIS Revisions CMS decided to go forward with a largescale effort to revise OASIS for three reasons: A. To address issues raised by the HHA providers B. To address suggestions made by IOM, MedPAC and NQF, including need to expand home health quality measurement to include care processes, and C. To align OASIS measures and harmonize items with other instruments being developed to measure care across post-acute care settings 8

OASIS-C Development & Testing 9

Development of OASIS-C From the first version of OASIS, CMS anticipated that the data set would evolve To oversee the evolution of OASIS, CMS convened a series of TEPs Reviewed recommendations from providers, MedPAC and NQF 10

Draft OASIS-C In 2006, CMS funded a study conducted by Abt Associates, University of Colorado and Case Western Reserve University to develop and test a revised OASIS which would: respond to the input from stakeholders; and include data items that could be used to support a set of new process measures By late 2007, a draft version of the OASIS-C was ready for field testing 11

OASIS-C Field Testing Summer 2008 11 agencies from 3 states: various agency sizes, types locations, electronic vs paper record data collection 68 RNs and PTs 370 OASIS-C assessments/183 patients Conditions targeted by new OASIS-C process measures: diabetes, heart failure, pressure ulcers 12

Field Testing Results Time: OASIS-C field test time similar to previous OASIS-B1 estimates (exception: transfer) Inter-rater reliability: agreement between raters ranged from slight to almost perfect Validity: Could verify OASIS-C response with clinical record consistently Clinician input: field test clinicians provided specific feedback on needed changes 13

Post-Field Test Revisions Revisions to field test version based on: Feedback from field testing Internal review to increase harmonization Input from National Quality Forum Public comments 14

Public Comments Public comment period: Nov 08 Jan 09 Many commenters expressed support for proposed changes to the OASIS Improved relevance, usability, consistency and clarity OASIS item deletions Improvements to wound items, ADLs, emergency room and hospitalization items Incorporation of best practices All suggestions were considered by CMS and, in many cases, they were adopted 15

Final Version of OASIS-C A refined version of OASIS-C was submitted to OMB spring 2009 The instrument was minimally revised to correct identified problems (i.e. skip patterns, etc.) and the final version was approved by OMB summer 2009 The OASIS-C Guidance Manual contains the OASIS-C data collection instruments for each time point 16

OASIS-C Overview of Changes 17

Changes in Number of OASIS Items For those of you keeping score, that is a total of two more items across all time points! Time Point B1 C Net Change (C - B1) SOC 77 79 2 ROC 77 79 2 Follow-up 31 32 1 Transfer 11 19 8 Discharge 72 61-11 Death at home 4 5 1 Patient Tracking 18 17-1 18

Why the Increase at Transfer? Additional items needed to: (a) (b) Calculate additional quality measures related to reasons for hospitalization Assess care processes that potentially can reduce the rate of acute care hospitalization CMS interested in what happens at transfer as a way to focus on improvement in acute care hospitalization Critical to examine the reasons for and reduce the rate of acute care hospitalization 19

Impact on Home Health Payment & Quality Reporting OASIS-C item revisions tested to insure no impact on the payment algorithm Detailed information about new process and outcome measures and the reporting schedule will be addressed later in this session 20

New Numbering System Tracking Items Clinical Record Items Patient History and Diagnoses Living Arrangements Sensory Status Integumentary Status Respiratory Status Cardiac Status M0010 M0150 M0080 M0110 M1000s M1100 M1200s M1300s M1400s M1500s 21

New Numbering System Elimination Status Neuro/ Emotional/ Behavioral Status ADLs/ IADLs Medications Care Management Therapy Need and Plan of Care Emergent Care Data Collected at TF/ DC M1600s M1700s M1800s + M1900s M2000s M2100s M2200 M2300 M2400s, M0903+M0906 22

Highlights of OASIS Changes Deleted items not used for payment, quality reports, or risk adjustment Replaced some eliminated items with items that capture the information in a more efficient way 23

Highlights of OASIS Changes Updated clinical terminology & concepts Improved accuracy in measurement of patient status and ability to show progress 24

OASIS-C Expanding Home Health Quality Measurement 25

Expanded HH Quality Measures Conceptually, quality of care can be measured in several areas, including: Access Structure Patient Experience Outcome Process 26

Expanded HH Quality Measures Process measures: Assess the health care services provided Assess adherence to recommendations for clinical practice based on evidence or consensus Can identify specific areas of care that may require improvement 27

Expanded HH Quality Measures Research has identified several evidence-based best practice processes relevant for home care patients Process items integrated into the OASIS-C facilitate the measurement of the rate of home health agency use of these evidence-based processes of care. 28

Benefits of Measuring Processes Agency performance improvement activities Promoting the use of best practices across the home health industry and across settings of care Public reporting of care processes that are under agency control Possible quality-based purchasing systems in the future 29

Incorporating Process Items into OASIS But why is CMS putting process items into OASIS? Isn t the OASIS a patient assessment tool? Not exactly OASIS is a dataset designed to collect information on the quality of home health care Integrating process items into the OASIS data set is the least burdensome method of collecting the data needed to calculate process measures for HHAs 30

Process Items 3 Points to Remember 1. Care processes in the OASIS-C are not mandated under the current Conditions of Participation 2. A rate of 100% is not expected for any agency for any measure 3. Process measures in OASIS-C are not an all-inclusive set of all evidence-based practices for home health care 31

OASIS-C Data Collection Conventions & Exceptions 32

Data Collection Conventions Time Period Convention #1 - Understand the time period under consideration for each item. Report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance Each M item has a specific assessment time period Most are Day of Assessment Many have other assessment time periods 33

Data Collection Conventions Time Period (M1900) Prior Functioning ADL/IADL: Indicate the patient s usual ability with everyday activities prior to this current illness, exacerbation, or injury. Check only one box in each row. Functional Area a. Self-Care (e.g., grooming, dressing, and bathing) Independent Needed Some Help Dependent b. Ambulation c. Transfer d. Household tasks (e.g., light meal preparation, laundry, shopping ) 34

Data Collection Conventions Usual Status Convention #2 - If the patient s ability or status varies on day of the assessment, report patient s usual status or what is true greater than 50% of the assessment time frame Unless the item specifies differently Example of Exception: (M2020) Management of Oral Medications M2020 is now in the medication domain and addresses patient s ability to manage ALL oral medications ALL the time. 35

Data Collection Conventions Referring to Prior Assessments Convention #4 -Responses to items documenting a patient s current status should be based on independent observation of the patient s condition and ability at the time of the assessment without referring back to prior assessments unless collection of the item includes review of the care episode (e.g., process items) 36

Data Collection Conventions Referring to Prior Assessments (M2400) Intervention Synopsis: (Check only one box in each row.) Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? 37

Data Collection Conventions Reviewing Prior Documentation Convention #5 - Combine observation, interview, and other relevant strategies to complete OASIS data items as needed When assessing physiologic or functional health status, direct observation is the preferred strategy However, it is acceptable to review the hospital discharge summary to identify inpatient procedures and diagnoses at Start of Care, or examine the care notes to determine if a physician-ordered intervention was implemented at Transfer or Discharge 38

Data Collection Conventions One Clinician Rule Convention #13 - Only one clinician takes responsibility for accurately completing a comprehensive assessment although for selected items, collaboration is appropriate Example of Exception: (M2000) Drug Regimen Review Ch 3 guidance indicates that portions of the drug regimen review may be completed by agency staff other than the clinician responsible for completing the SOC/ROC OASIS must be communicated to the clinician responsible for the SOC/ROC OASIS assessment so that the appropriate response for M2000 may be selected. 39

Highlights of OASIS-C Changes by Section 40

What This Presentation Will and Won t Provide IMPORTANT: This review will NOT take the place of a careful review of the OASIS-C Guidance Manual and frequent referencing of the manual while OASIS-C is still new to you. We will provide: Highlights of new and revised guidance Links to available resources for learning more about OASIS-C data collection guidance We will not provide: Complete guidance on how to answer every item in OASIS-C 41

Patient Tracking Domain Changes to Pt Tracking Items No NEW items Several revised items 1 dropped item Medicaid Provider Number M0140 Race/Ethnicity no longer has the option of Unknown not an acceptable response per OMB 42

Clinical Record Items Domain Timely Care Two new items: (M0102) Date of Physician-ordered Start of Care (Resumption of Care) (M0104) Date of Referral Added to support process measure on Timely Care Collected only at SOC/ROC 43

Clinical Record Items Domain Timely Care (M0102) Date of Physician-ordered Start of Care (Resumption of Care) If the physician indicated a specific date for SOC/ROC, enter the date and SKIP M0104 Otherwise, select NA No specific SOC date ordered - and GO TO M0104 to enter date of referral If original physician-ordered SOC/ROC date gets delayed, the updated/revised date would be entered 44

Clinical Record Items Domain Timely Care (M0104) Date of Referral Most recent date that verbal, written, or electronic authorization to begin home care was received by the HHA If SOC/ROC gets delayed, enter the date the agency received the updated/revised referral information Communications from assisted living facility staff or family do not constitute a referral 45

Patient History & Diagnosis Domain Inpatient Facility Discharge (M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.) 1 - Long-term nursing facility (NF) 2 - Skilled nursing facility (SNF / TCU) 3 - Short-stay acute hospital (IPPS) 4 - Long-term care hospital (LTCH) 5 - Inpatient rehabilitation hospital or unit (IRF) 6 - Psychiatric hospital or unit 7 - Other (specify) NA - Patient was not discharged from an inpatient facility [ Go to M1016 ] 46 46

Patient History & Diagnosis Domain Inpatient Procedures (M1012) List each Inpatient Procedure and the associated ICD-9-CM procedure code relevant to the plan of care Procedures received during an inpatient stay ending within 14 days of a home health admission Relevant to the home health plan of care Based on the info available at SOC/ROC Has NA and Unknown Response Options Clinicians only need to respond to the best of their ability Intended to be used for Risk Adjustment 47

Patient History & Diagnosis Domain Diagnoses and Symptom Control M1020/M1022/M1024 Primary and Other Diagnoses, Symptom Control, and Payment Diagnoses Renumbered items replace M0230/M0240/M0246 New Guidance Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided Understand each patient s specific clinical status before selecting and assigning each diagnosis 48

Patient History & Diagnosis Domain Patient Prognosis Two new items on patient prognosis (M1032) Risk for Hospitalization (M1034) Overall Status Replace 3 OASIS-B1 items (M0260) Overall Prognosis (M0270) Rehabilitative Prognosis (M0280) Life Expectancy Collected at SOC/ROC Used for risk adjustment 49

Patient History & Diagnosis Domain Patient Prognosis (M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.) 1 - Recent decline in mental, emotional, or behavioral status 2 - Multiple hospitalizations (2 or more) in the past 12 months 3 - History of falls (2 or more falls - or any fall with an injury - in the past year) 4 - Taking five or more medications 5 - Frailty indicators, e.g., weight loss, self-reported exhaustion 6 - Other 7 - None of the above 50 50

Patient History & Diagnosis Domain Patient Prognosis (M1034) Overall Status: Which description best fits the patient s overall status? (Check one) 0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient s age). 1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient s age). 2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death. 3 - The patient has serious progressive conditions that could lead to death within a year. UK - The patient s situation is unknown or unclear. 51

Patient History & Diagnosis Domain Immunizations 4 New Items report immunization status (M1040) Influenza Vaccine (M1045) Reason Influenza Vaccine not received (M1050) Pneumococcal Vaccine (M1055) Reason PPV not received Collected at Transfer & Discharge Used for publicly-reported measures of immunization rates Harmonized with other care settings 52

Patient History & Diagnosis Domain Immunizations Focus: is patient up to date on their flu and PPV vaccines when they leave the care of your agency? Initial question: did you give the vaccine during the episode? Asked at Transfer/Discharge episode defined as from SOC/ROC to transfer or DC If the answer is yes, you are done Follow-up question: if the answer is no, then explain why 53

Patient History & Diagnosis Domain Immunizations (M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year s influenza season (October 1 through March 31) during this episode of care? 0 - No 1 - Yes [ Go to M1050 ] NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season [ Go to M1050 ] 54

Patient History & Diagnosis Domain Immunizations (M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason: 1 - Received from another health care provider (e.g., physician) 2 - Received from your agency previously during this year s flu season 3 - Offered and declined 4 - Assessed and determined to have medical contraindication(s) 5 - Not indicated; patient does not meet age/condition guidelines for influenza vaccine 6 - Inability to obtain vaccine due to declared shortage 7 - None of the above 55

Patient History & Diagnosis Domain Immunizations (M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC Transfer/Discharge)? 0 - No 1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ] 56

Patient History & Diagnosis Domain Immunizations (M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason: 1 - Patient has received PPV in the past 2 - Offered and declined 3 - Assessed and determined to have medical contraindication(s) 4 - Not indicated; patient does not meet age/condition guidelines for PPV 5 - None of the above 57

Living Arrangements Domain Patient Living Situation Replaced 6 Oasis-B1 items collected at SOC/ROC: (M0300) Current Residence: (M0340) Patient Lives With: (M0350) Assisting Person(s) Other than Home Care Agency Staff (M0360) Primary Caregiver (M0370) How Often does the patient receive assistance from the primary caregiver? (M0380) Type of Primary Caregiver Assistance With 3 New Items collected at SOC/ROC 58

Living Arrangements Domain Patient Living Situation First item: (M1100) Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only.) Living Arrangement Around the clock Availability of Assistance Regular Daytime Regular Nighttime Occasional/ short-term assistance No assistance available a. Patient lives alone 01 02 03 04 05 b. Patient lives with other person(s) in the home c. Patient lives in congregate situation (e.g. assisted living) 06 07 08 09 10 11 12 13 14 15 59

Living Arrangements Domain Patient Living Situation (M1100) Patient Living Situation To select the appropriate response: First, determine living arrangement whether the patient lives alone, in a home with others, or in a congregate setting; Second, determine availability of assistance how frequently caregiver(s) are in the home and available to provide assistance Review guidance in the manual to become familiar with the definitions 60

Sensory Status Domain Speech & Hearing Changes to speech and hearing: OASIS B-1 item (M0400) Hearing and Ability to Understand Spoken Language split out into: (M1210) Ability to hear (with hearing aid or hearing appliance if normally used) (M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used) Response to industry request and goal of improved accuracy Both collected at SOC/ROC Candidates for use in risk adjustment 61

Sensory Status Domain Pain Assessment Deleted - (M0430) Intractable Pain Added (M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient s ability to communicate the severity of pain)? 0 - No standardized assessment conducted 1 - Yes, and it does not indicate severe pain 2 - Yes, and it indicates severe pain 62

Sensory Status Domain Pain Assessment M1240 Pain Assessment CMS does not mandate pain assessment or endorse a specific tool, but tool selected must be: Conducted according to instructions Appropriate for patient Standardized tool is one that includes a standard response scale (e.g., 0-10 pain scale) Severe pain is defined according to the scoring system for the standardized tool being used See links to resources in Ch 5 of Guidance Manual 63

Integumentary Status Domain Pressure Ulcers Many changes to Pressure Ulcer items: (M1300) Pressure Ulcer Risk Assessment - NEW (M1302) Pressure Ulcer Risk - NEW (M1307) Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge - NEW (M1308) Current Number of Pressure Ulcers Table Revised (M1310/M1312/M1314) Pressure Ulcer Length, Width & Depth - NEW 64

Integumentary Status Domain Pressure Ulcer Risk Assessment (M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers? 0 - No assessment conducted [ Go to M1306 ] 1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool 2 - Yes, using a standardized tool, e.g., Braden, Norton, other 65

Integumentary Status Domain Pressure Ulcer Risk Assessment (M1302) Does this patient have a Risk of Developing Pressure Ulcers? 0 - No 1 - Yes If using standardized tool, use tool s scoring parameters to identify risk If using clinical factors, clinician or agency must define what constitutes risk 66

Integumentary Status Domain Pressure Ulcers Stage II or Higher (M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"? 0 - No [ Go to M1322 ] 1 - Yes At SOC/ROC, allows the clinician to skip the next 6 questions if the patient does not have a Stage II or higher pressure ulcer 67

Integumentary Status Domain Pressure Ulcers Stage II or Higher Clinicians will need to study and refer to Chapter 3 in the guidance manual to know how to respond to M1306 and M1308 Guidance about counting fully epithelialized Stage II, III and IV ulcers has not changed Closed Stage II are still NOT counted in this item Closed Stage III and IV ulcers are still counted 68

Integumentary Status Domain Unhealed Pressure Ulcers (M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge 1 - Was present at the most recent SOC/ROC assessment 2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified: / / month / day / year NA - No non-epithelialized Stage II pressure ulcers are present at discharge Collected at Discharge ONLY 69

Integumentary Status Domain Unhealed Pressure Ulcers Respond 1 or 2 only if discharging with an unhealed Stage II pressure ulcer If more than one unhealed Stage II pressure ulcer, determine which one is the oldest If the oldest Stage II Pressure Ulcer was present at the last SOC/ROC, select response 1 If the oldest Stage II Pressure Ulcer present at discharge developed since the last SOC/ROC Select response 2 Record the date the ulcer was first identified 70

Integumentary Status Domain Pressure Ulcer Count (M1308) Current Number of Unhealed (non epithelialized) Pressure Ulcers at Each Stage: (Enter 0 if none; excludes Stage I pressure ulcers) 71

Integumentary Status Domain Pressure Ulcer Count What s new in M1308: Stage I pressure ulcers are not counted Number of ulcers at each stage is documented Unstageable ulcers are broken out into reason for unstageable 2nd column at FU and DC identifies ulcers that were present on admission Tracks whether an ulcer developed during a quality episode 72

Integumentary Status Domain Pressure Ulcer Count For Column 1, report the number (M1308) of unhealed Current Number of Unhealed Stage II (non-epithelialized) or higher Pressure Ulcers at Each Stage: pressure (Enter ulcers 0 on if the none; excludes Stage I pressure ulcers) current day of assessment. This column must be completed at Start of Care, Resumption of Care, Follow-up and Discharge. 73

Integumentary Status Domain Pressure Ulcer Count For Column (M1308) 2, report Current the Number of Unhealed number of unhealed (non-epithelialized) Pressure Ulcers at Each Stage: Stage II or higher (Enter 0 if none; excludes Stage I pressure ulcers) pressure ulcers that were identified in column 1 and were present on the most recent SOC/ROC. Column 2 is completed only at Follow-up and Discharge. 74

Integumentary Status Domain Pressure Ulcer Dimensions M1310, M1312 and M1314 Pressure Ulcer Length, Width and Depth Reports dimensions of pressure ulcer with the largest surface area that is: Stage III or IV not covered with epithelial tissue Unstageable due to eschar or slough Skip if no stage III, IV or unstageable If multiple open stage III, IV or unstageable ulcers, measure to see which has largest surface area 75

Integumentary Status Domain Pressure Ulcer Dimensions M1310, M1312 and M1314 Pressure Ulcer Length, Width and Depth Record dimensions of the pressure ulcer with the largest surface area in centimeters Length = longest head to toe Width = greatest width perpendicular to length Depth = from visible surface to deepest area Chapter 3 of OASIS-C Guidance Manual has further instructions and pictures Clinicians must become familiar with the manual instructions to respond accurately 76

Integumentary Status Domain Pressure Ulcer Healing Status M1320 Status of Most Problematic (Observable) Pressure Ulcer 0 - Newly epithelialized 1 - Fully granulating 2 - Early/partial granulation 3 - Not healing NA - No observable pressure ulcer 77

Integumentary Status Domain Pressure Ulcer Healing Status M1320 Status of Most Problematic (Observable) Pressure Ulcer Response 0 Newly Epithelialized - epithelial tissue has completely covered wound surface regardless of how long the pressure ulcer has been re-epithelialized Response 1 Fully Granulating - epithelial tissue has not completely covered the wound surface Response 2 Early/partial Granulation - necrotic or avascular tissue covers <25% of the wound bed Response 3 - Not Healing, for a Stage III or IV pressure ulcer if the wound has 25% necrotic or avascular tissue Refer to the OASIS-C Guidance Manual and the WOCN OASIS Guidance Document 78

Integumentary Status Domain Stage 1 Pressure Ulcers (M1322) Current Number of Stage I Pressure Ulcers Identifies the presence of Stage I pressure ulcers at SOC/ROC, FU and DC NPUAP definition of Stage I ulcer: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. 79

Integumentary Status Domain Most Problematic Pressure Ulcer (M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer Final item in pressure ulcer section Identifies the stage of the most problematic observable Stage 1 or higher pressure ulcer Skip if no observable pressure ulcers Most problematic may be the largest, most advanced stage, most difficult to access for treatment, most difficult to relieve pressure, etc Used for payment and quality measures 80

Integumentary Status Domain Stasis Ulcers Three items on stasis ulcers: (M1330) Does this patient have a Stasis Ulcer? (M1332) Current Number of (Observable) Stasis Ulcer(s) (M1334) Status of Most Problematic (Observable) Stasis Ulcer Review the manual to see changes to skip patterns, response options 81

Integumentary Status Domain Surgical Wounds Two items on surgical wounds: (M1340) Does this patient have a Surgical Wound? (M1342) Status of Most Problematic (Observable) Surgical Wound Both collected at SOC, ROC, FU and DC Used for payment and quality measurement Item counting number of surgical wounds was dropped 82

Integumentary Status Domain Surgical Wounds (M1340) Does this patient have a Surgical Wound? 0 - No [ Go to M1350 ] 1 - Yes, patient has at least one (observable) surgical wound 2 - Surgical wound known but not observable due to non-removable dressing [ Go to M1350 ] Non-observable = covered by a dressing (or cast) which cannot be removed per physician order 83

Integumentary Status Domain Surgical Wounds (M1342) Status of Most Problematic (Observable) Surgical Wound: 0 - Newly epithelialized 1 - Fully granulating 2 - Early/partial granulation 3 - Not healing A surgical site can be considered newly epithelialized for approximately 30 days after epithelial tissue covers the surface of the wound After 30 days, it is considered a scar and no longer reported 84

Integumentary Status Domain Other Wounds (M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency? 0 - No 1 - Yes Skin lesions or open wounds that are not receiving clinical intervention from the home health agency should not be considered when responding to this question 85

Respiratory Status Domain Shortness of Breath & Treatments Same two items: (M1400) When is the patient dyspneic or noticeably Short of Breath? Response 0 no longer says never (M1410) Respiratory Treatments utilized at home Response 3 now includes Bi-PAP Both collected at SOC, ROC, FU and DC M1400 used for payment and quality measurement 86

Cardiac Status Domain Heart Failure Symptoms Two new items: (M1500) Symptoms in Heart Failure Patients (M1510) Heart Failure Symptom Follow-up Collected at Transfer and DC Time Period under consideration at or since the previous OASIS Assessment Only for patients with a diagnosis of heart failure in OASIS Used for quality measurement 87

Cardiac Status Domain Heart Failure Symptoms (M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment? 0 - No [Go to M2004 at TRN; Go to M1600 at DC] 1 - Yes 2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ] NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC ] 88

Cardiac Status Domain Response to Heart Failure Symptoms (M1510) Heart Failure Follow-up: Asks clinician to identify ALL actions that have been taken to respond to heart failure symptoms Patient s physician (or other primary care practitioner) contacted the same day Patient advised to get emergency treatment (e.g., call 911 or go to emergency room) Implemented physician-ordered patient-specific established parameters for treatment Patient education or other clinical interventions Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.) 89

Elimination Status Domain Urinary Incontinence (M1615) When does Urinary Incontinence occur? 0 - Timed-voiding defers incontinence 1 - Occasional stress incontinence 2 - During the night only 3 - During the day only 4 - During the day and night 90

Elimination Status Domain Urinary Incontinence (M1615) New response options: 1 - Occasional stress incontinence Select if the ONLY incontinence that occurs is when patient is unable to prevent escape of relatively small amounts of urine with activities such as coughing, sneezing, laughing, lifting, standing up other activities (stress) which can increase abdominal pressure 3 - During the day only - when incontinence occurs only during the day 91

Neuro/ Emotional/Behavioral Status Domain Confusion/Anxiety (M1710) When Confused (Reported or Observed Within the Last 14 Days) (M1720) When Anxious (Reported or Observed Within the Last 14 Days) timeframe now specified as the past two weeks collected at SOC/ROC and Discharge used for quality measures 92

Neuro/ Emotional/Behavioral Status Domain Depression Screening (M1730) Depression Screening Asks if the patient has been screened for depression, using a standardized depression screening tool Allows clinician to document if assessed: not assessed assessed using the PHQ-2 scale* assessed different standardized assessment Allows clinician to document results of screening if conducted *Copyright Pfizer Inc. All rights reserved. 93

Neuro/ Emotional/Behavioral Status Domain Depression Screening PHQ-2 scale. Ask patient: Over the last two weeks, how often have you been bothered by any of the following problems? Copyright Pfizer Inc. All rights reserved. Reproduced with permission. 94

Neuro/ Emotional/Behavioral Status Domain Depression Screening Select 0 if a standardized depression screening was not conducted. Select 1 if the PHQ-2 is completed when responding to the question Select 2 if the patient is screened with a different standardized assessment and need for further evaluation indicated Select 3 if the patient is screened with a different standardized assessment and no need for further evaluation indicated 95

ADL/IADL Domain ADL/IADL Conventions Identify ability, not necessarily actual performance Identify patient's ability to safely perform included tasks, given current physical status mental/emotional/cognitive status activities permitted, and environment For multi-task items, if the patient s ability varies between the different tasks, report what is true in a majority of the included tasks, giving more weight to tasks that are more frequently performed 96

ADL/IADL Domain Major Changes Deletions: Transportation, Shopping, Housekeeping, Laundry Prior status 14 days before the start/resumption of care Additions: Prior Status grid Toileting Hygiene and Fall Risk Assessment Revisions: Wording changes (safely) to numerous items New response scales (bathing, ambulation) Bathing now includes ability to perform the tub/shower transfer Toileting now includes transferring on and off the toilet Medication items now in their own domain 97

ADL/IADL Domain Bathing (M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). 0 - Able to bathe self in shower or tub independently, including getting in and out of tub/shower. 1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of the tub/shower. 2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas. 98

ADL/IADL Domain Bathing (M1830) Bathing (continued) 3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision. 4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode. 5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath. 6 - Unable to participate effectively in bathing and is bathed totally by another person. 99

ADL/IADL Domain Toilet Transferring (M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. 0 - Able to get to and from the toilet and transfer independently with or without a device. 1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer. 2 - Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance). 3 - Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently. 4 - Is totally dependent in toileting. 100

ADL/IADL Domain Toileting Hygiene (M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment. 0 - Able to manage toileting hygiene and clothing management without assistance. 1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient. 2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing. 3 - Patient depends entirely upon another person to maintain toileting hygiene. 101

ADL/IADL Domain Toileting Hygiene (M1845) Toileting Hygiene Assistance refers to assistance from another person by verbal cueing/reminders, supervision, and/or stand-by or hands-on assistance If patient can participate in hygiene and/or clothing management, but needs some assist with either or both activities, select response 2 102

ADL/IADL Domain Ambulation/Locomotion (M1860)Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. New response options: 1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings. 2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces. 103

ADL/IADL Domain Prior ADL/IADL Functioning Dropped prior status - replaced with grid: (M1900) Prior Functioning ADL/IADL: Indicate the patient s usual ability with everyday activities prior to this current illness, exacerbation, or injury. Check only one box in each row. Collected at SOC/ROC Used for Risk Adjustment 104

ADL/IADL Domain Prior ADL/IADL Functioning Guidance Manual provides definitions of dependence Independent - patient had the ability to complete the activity by him/herself (with or without assistive devices) without physical or verbal assistance from a helper Needed some help - patient contributed effort but required help from another person to accomplish the task/activity safely Dependent - patient was physically and/or cognitively unable to contribute effort toward completion of the task, and the helper must contribute all the effort Refer to the manual for specific tasks which are included in each functional area 105 105

ADL/IADL Domain Fall Risk Assessment (M1910) Has the patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)? 0 - No multi-factor falls risk assessment conducted. 1 - Yes, and it does not indicate a risk for falls. 2 - Yes, and it indicates a risk for falls. Select 0 if falls risk assessment: Was not done at all Was not done using standardized validated multi-factor fall risk tool Was not done in the assessment time frame Was not done by the assessing clinician 106

ADL/IADL Domain Fall Risk Assessment Multi-factor falls risk assessment May be a single standardized, validated comprehensive multi-factor falls risk assessment tool May incorporate several tools as long as one of them is standardized and validated Determining risk level Use the scoring parameters specified in the tool to identify if a patient is at risk for falls Select response 1 if the standardized response scale rates the patient as no-risk or low-risk Select response 2 if the standardized response scale rates the patient as anything above low-risk 107

Medication Domain Changes in OASIS-C Medication items are now in their own domain Deletions: Items assessing inhalant medications Revisions: Prior column at SOC/ROC replaced with a single prior functioning grid item Instructions on measuring the majority of the time have been revised for items assessing patient independence in managing medications Additions: Process items reporting implementation of best practices for medication reconciliation and patient/caregiver education 108

Medication Domain Drug Regimen Review (M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance? 0 - Not assessed/reviewed [Go to M2010 ] 1 - No problems found during review [Go to M2010 ] 2 - Problems found during review NA - Patient is not taking any medications [Go to M2040] Collected at SOC/ROC 109

Medication Domain Drug Regimen Review All medications includes prescribed and over the counter, administered by any route Ch 3 of OASIS-C Guidance Manual defines a problem for responses 1 and 2 is (med list mismatch, symptoms poorly controlled, patient confused about directions) Ch 5 of OASIS-C Guidance Manual has online resources for evaluating drug reactions, side effects, interactions, etc. 110

Medication Domain Medication Follow-up (M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation? 0 - No 1 - Yes Collected at SOC/ROC 111

Medication Domain Medication Follow-up Clinically significant medication issues pose a threat to patient health and safety, in the clinician s judgment examples in the itemby-item guidance in Chapter 3 Contact with physician defined as communication to the physician that appropriately conveys the message of patient status Response 1 Yes should only be selected if physician responds to HHA communication 112

Medication Domain Medication Follow-up Portions of the drug regimen review or communication with the physician may be completed by agency staff other than the clinician responsible for completing the SOC/ROC OASIS Information on drug regimen review findings must be communicated to the clinician responsible for the SOC/ROC OASIS assessment This does not violate the one clinician rule for completion of the assessment 113

Medication Domain Medication Intervention (M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation? 0 - No 1 - Yes NA - No clinically significant medication issues identified since the previous OASIS assessment Collected at Transfer & Discharge 114

Medication Domain High Risk Drug Education (M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur? 0 - No 1 - Yes NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications Collected at SOC/ROC 115

Medication Domain High Risk Drug Education High-risk medications those that have considerable potential for causing significant patient harm when used erroneously as identified by quality organizations (Institute for Safe Medication Practices and JCAHO High Alert Medication List. Beer's Criteria, etc.) See Ch 5 of the Guidance Manual for links Clinicians may collaborate to ensure patient/caregiver receives education on high risk meds 116

Medication Domain Drug Education Intervention (M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects and how and when to report problems that may occur? 0 - No 1 - Yes NA - Patient not taking any drugs Collected at Transfer & Discharge 117

Medication Domain Drug Education Intervention Effective, safe management of medications includes: Knowledge of effectiveness, Potential side effects and drug reactions, and When to contact the appropriate care provider Includes all medications the patient is taking, prescribed and over-the-counter, by any route 118

Medication Domain Medication Management (M2020) Management of Oral Medications (M2030) Management of Injectable Medications No prior status columns Now references ability to take all medications reliably and safely at all times If ability varies between the meds, report medication that requires the most assistance Ch 3 now addresses the use of planner devices If patient sets up "planner device" and is able to take meds at correct dose/times as a result, correct response = 0 If another person must set up a planner device, correct response = 1 119

Medication Domain Management of Oral Medications Improved ability to show progress Response 1 now split into able to take medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart Response 2 now references ability to take medication(s) at the correct times if given reminders by another person 120

Medication Domain Prior Medication Management (M2040) Prior Medication Management: Indicate the patient s usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury. Check only one box in each row. Functional Area Independent Needed Some Help Dependent Not Applicable a. Oral medications b. Injectable medications 121

Medication Domain Prior Medication Management Guidance Manual provides definitions of dependence Independent - patient had the ability to complete the activity by him/herself (with or without assistive devices) without physical or verbal assistance from a helper Needed some help - patient required help from another person to accomplish the task/activity safely Dependent - patient was unable to perform any of the task/activity 122

Care Management Types and Sources of Assistance (M2100) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed. (Check only one box in each row.) 123

Care Management Types and Sources of Assistance For M2100, consider the aspect that represents the most need and the availability and ability of caregiver(s) to meet that need When determining patient needs in each row, respond based on the patient s greatest need in that category (e.g., ADL with greatest level of dependence) When determining caregiver s ability and willingness, select the response that represents the greatest need 124

Care Management Frequency of Assistance (M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)? Collected at SOC/ROC and DC for risk adjustment Responses include Daily, 3 or more times per week, 1-2 times per week, Less than weekly, None, or Unknown (Unknown not allowed at DC) Select the response that reports how often the patient receives assistance with any ADL or IADL 125

Therapy Need and Plan of Care Plan of Care Synopsis (M2250) Plan of Care Synopsis: (Check only one box in each row.) Does the physician-ordered plan of care include the following: 126

Therapy Need and Plan of Care Plan of Care Synopsis Responding that the current physician-ordered plan of care includes a plan/intervention means the patient condition has been discussed with the physician there is agreement as to the plan of care between the home health staff and the physician if prior to the receipt of signed orders, the clinical record should reflect evidence of communication with the physician to include specified best practice interventions in the POC 127

Therapy Need and Plan of Care Plan of Care Synopsis Review Chapter 3 guidance carefully for: Acceptable POC interventions Example: Row a specific clinical parameters may include ranges or limits for vital signs, weight, wound measurements, pain intensity ratings etc Guidance on timeframes POC orders must be in place within the 5-day SOC or 2- day ROC window to respond Yes Guidance on collaboration Assessing clinician can wait until after other disciplines complete assessments and developed their care plans Does not violate one clinician rule 128

Therapy Need and Plan of Care Emergent Care (M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)? Response options now include with/without hospitalization Now refers exclusively to care provided in a hospital emergency department Collected at Transfer or Discharge for quality measurement Timeframe: since last OASIS assessment See Ch 3 for guidance on special circumstances such as holds for observation 129

Therapy Need and Plan of Care Emergent Care Reason (M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply) Refers exclusively to care provided in a hospital emergency department New response options should decrease the use of other and provide more useful data If more than one reason contributed to ED visit, mark all appropriate responses If multiple ED visits, include the reasons for all visits Collected at Transfer or Discharge for quality measurement Timeframe: since last OASIS assessment 130

Data Collected at TRF/DC Intervention Synopsis (M2400) Intervention Synopsis: (Check only one box in each row.) Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? 131